Update on the perioperative management of diabetes mellitus

Abstract

Learning objectivesBy reading this article, you should be able to:•Explain the mechanism of action of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and know the perioperative recommendation.•Outline the indications and beneficial effects of sodium-glucose transporter 2 inhibitors (SGLT2Is) and the main risks of their use in the perioperative period.•Understand the relevant characteristics of different types of diabetes.•Discuss the limitations and concerns for clinicians and the patient on using a continuous glucose monitor (CGM) or continuous subcutaneous insulin infusion (CSII) pump in the perioperative period.Key points•Good preoperative assessment and planning are critical for the optimal perioperative management of diabetes mellitus.•Clinicians must ascertain the type of diabetes in all patients, including children.•Guidelines strongly recommend preoperative HbA1c measurements.•No continuous glucose monitor or continuous subcutaneous insulin infusion pump has been certified for perioperative use.•After surgery, a basal-bolus insulin regimen is preferable to a sliding-scale (short-acting, bolus-only) insulin protocol. By reading this article, you should be able to:•Explain the mechanism of action of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and know the perioperative recommendation.•Outline the indications and beneficial effects of sodium-glucose transporter 2 inhibitors (SGLT2Is) and the main risks of their use in the perioperative period.•Understand the relevant characteristics of different types of diabetes.•Discuss the limitations and concerns for clinicians and the patient on using a continuous glucose monitor (CGM) or continuous subcutaneous insulin infusion (CSII) pump in the perioperative period. •Good preoperative assessment and planning are critical for the optimal perioperative management of diabetes mellitus.•Clinicians must ascertain the type of diabetes in all patients, including children.•Guidelines strongly recommend preoperative HbA1c measurements.•No continuous glucose monitor or continuous subcutaneous insulin infusion pump has been certified for perioperative use.•After surgery, a basal-bolus insulin regimen is preferable to a sliding-scale (short-acting, bolus-only) insulin protocol. Diabetes mellitus is a public health concern, with a steadily increasing global prevalence. According to the International Diabetes Federation (IDF), ∼536 million adults (aged 20–79 yrs) worldwide were living with diabetes in 2019, representing a prevalence of 10.5%.1International Diabetes FederationIDF Diabetes Atlas.10th Edn. IDF, Brussels, Belgium2019Google Scholar Diabetes mellitus is more frequently prevalent in surgical patients compared with the general population, given the increased risk of surgical interventions in individuals with diabetes-related complications, although there are substantial differences between surgical specialties. A meta-analysis of 90 studies, including 866,427 surgical records, reported an overall prevalence of diabetes of 17%.2Martin E.T. Kaye K.S. Knott C. et al.Diabetes and risk of surgical site infection: a systematic review and meta-analysis.Infect Control Hosp Epidemiol. 2016; 37: 88-99Google Scholar The prevalence of diabetes was highest in patients presenting for cardiovascular surgery (up to 39%), followed by orthopaedic surgery.2Martin E.T. Kaye K.S. Knott C. et al.Diabetes and risk of surgical site infection: a systematic review and meta-analysis.Infect Control Hosp Epidemiol. 2016; 37: 88-99Google Scholar Among patients undergoing bariatric surgery, the prevalence of type 2 diabetes was 26%.3Chang S.H. Stoll C.R.T. Song J. Varela J.E. Eagon C.J. Colditz G.A. The effectiveness and risks of bariatric surgery an updated systematic review and meta-analysis, 2003-2012.JAMA Surg. 2014; 149: 275-287Google Scholar The presence of diabetes in surgical patients is associated with an increased risk of perioperative complications, a prolonged hospital stay and higher rates of morbidity and mortality.2Martin E.T. Kaye K.S. Knott C. et al.Diabetes and risk of surgical site infection: a systematic review and meta-analysis.Infect Control Hosp Epidemiol. 2016; 37: 88-99Google Scholar,3Chang S.H. Stoll C.R.T. Song J. Varela J.E. Eagon C.J. Colditz G.A. The effectiveness and risks of bariatric surgery an updated systematic review and meta-analysis, 2003-2012.JAMA Surg. 2014; 149: 275-287Google Scholar Poor glycaemic control in diabetic surgical patients further exacerbates these risks.2Martin E.T. Kaye K.S. Knott C. et al.Diabetes and risk of surgical site infection: a systematic review and meta-analysis.Infect Control Hosp Epidemiol. 2016; 37: 88-99Google Scholar,3Chang S.H. Stoll C.R.T. Song J. Varela J.E. Eagon C.J. Colditz G.A. The effectiveness and risks of bariatric surgery an updated systematic review and meta-analysis, 2003-2012.JAMA Surg. 2014; 149: 275-287Google Scholar Studies have demonstrated a higher incidence of surgical site infections, delayed wound healing, cardiovascular events and respiratory complications in surgical patients with diabetes.2Martin E.T. Kaye K.S. Knott C. et al.Diabetes and risk of surgical site infection: a systematic review and meta-analysis.Infect Control Hosp Epidemiol. 2016; 37: 88-99Google Scholar,3Chang S.H. Stoll C.R.T. Song J. Varela J.E. Eagon C.J. Colditz G.A. The effectiveness and risks of bariatric surgery an updated systematic review and meta-analysis, 2003-2012.JAMA Surg. 2014; 149: 275-287Google Scholar Glucose metabolism plays a vital role in energy production and maintenance of blood glucose concentrations within a narrow range. In healthy individuals, sodium-glucose transporter 1 (SGLT1) and glucose transporter (GLUT) enzymes facilitate glucose uptake in response to oral intake. Furthermore, glucagon-like-peptide-1 (GLP-1) is secreted by the intestinal L-cells in response to eating.4Drucker D.J. Nauck M.A. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes.Lancet. 2006; 368: 1696-1705Google Scholar Binding of GLP-1 to its receptors stimulates insulin secretion from the pancreas. Insulin allows glucose to be transported into the cells, where it undergoes a series of enzymatic reactions, collectively known as glycolysis, to produce energy such as adenosine triphosphate (ATP). Excess glucose is stored in the liver and skeletal muscle as glycogen (glycogenesis). In people with diabetes mellitus, the regulation of glucose metabolism is impaired. The majority of patients presenting with impaired glucose control have type 2 diabetes mellitus (T2DM).5van Wilpe R. Hulst A.H. Siegelaar S.E. DeVries J.H. Preckel B. Hermanides J. Type 1 and other types of diabetes mellitus in the perioperative period. What the anaesthetist should know.J Clin Anesth. 2023; 84111012Google Scholar, 6van Wilpe R. Hulst A.H. Polderman J.A.W. et al.Less common types of diabetes mellitus: incidence and glucose control in the perioperative setting.J Clin Anesth. 2021; 75110460Google Scholar, 7Hulst A.H. Polderman J.A.W. Kooij F.O. et al.Comparison of perioperative glucose regulation in patients with type 1 vs type 2 diabetes mellitus: a retrospective cross-sectional study.Acta Anaesthesiol Scand. 2019; 63: 314-321Google Scholar In T2DM, the body develops insulin resistance, hampering glucose uptake into cells, or the pancreas fails to produce enough insulin to meet the body's demands. Nonetheless, around 10% of adult patients have T1DM or other less common forms of diabetes mellitus. In T1DM, the pancreas fails to produce insulin, which is caused by the (autoimmune) destruction of insulin-producing beta cells in the islets of Langerhans. Besides T1DM and T2DM, many other forms of DM with distinctive pathophysiology exist. Table 1 provides an overview of these different forms of diabetes, with defining characteristics and relevant points for perioperative management.Table 1Types of diabetes and specific concerns for the anaesthetist. CFRD, cystic fibrosis related diabetes; GDM, gestational diabetes mellitus; LADA, latent autoimmune diabetes in adults; MODY, maturity onset diabetes of the young; PTDM, post-transplant DM; T1DM/T2DM, type 1/2 diabetes mellitus.Type of diabetesPathophysiology and clinical featuresInsulin deficiencyPerioperative dysregulationPerioperative concerns1T1DM•Autoimmune destruction of pancreatic β-cells, leading to absolute insulin deficiencyAbsoluteCommon•Hypoglycaemia is common•Consider referral to DM care physician•Always need exogenous insulin source (basal insulin, pump or i.v. drip)2T2DM•Combination of insulin resistance and deficiency caused by diet, life-style and geneticsRelativeDepending on severity•Associated comorbidities•Depending on severityLADA•Autoimmune diabetes which does not manifest until adulthood. Clinically heterogenous group on the continuum between T1DM and T2DMVariableVariable•Do not omit basal insulin, especially if anti-GADi titre is high•Few data regarding perioperative glucose control3aMonogenetic diabetes (e.g. MODY or neonatal diabetes)•Rare forms of diabetes, typically as a result of genetic defects in β-cell function causing impaired insulin secretion. Clinical features depend on the subtype and genetic defectVariableVariable•Clinically heterogenous•MODY subtype 2 (15–50%, Table 2) is generally mild. Manage other types as T1DM or T2DM depending on phenotype3bPancreatic diabetes (e.g. pancreatitis) CFRD•Pancreatitis leads to islet tissue fibrosis and destruction, resulting in insulin and glucagon deficiency.VariableYes•Marked glycaemic variability and possibly unpredictable response to exogenous insulin3cEndocrinopathy-related DM•Insulin resistance and deficiency as a result of the excess release of counterregulatory hormones such as cortisol, GH/IGF-1 and catecholaminesLimitedYes•Commonly requires glycaemic monitoring and insulin (especially for phaeochromocytoma)•Beware of rebound hypoglycaemia after tumour related DM (e.g. and insulin resistance, increased and insulin is caused by of the in is associated with risk of with an increased risk of T2DM in glycaemic as glucose neonatal and neonatal hypoglycaemia in a Diabetes mellitus is of the common in and the of T1DM and T2DM in are is by the increasing incidence of in of the patients with T1DM are J. et in prevalence of type 1 and type 2 diabetes in and in the 2021; Scholar The between and T2DM is T2DM for 10% of T2DM for of patients in the J. et in prevalence of type 1 and type 2 diabetes in and in the 2021; Scholar the of patients with T1DM is the prevalence of with T2DM has increased more in the J. et in prevalence of type 1 and type 2 diabetes in and in the 2021; Scholar Furthermore, in with impaired insulin secretion to an clinical of Insulin are of insulin resistance, and the of islet a with DM not have T1DM, and a with and DM not have it is vital to to the type of diabetes in and and management between types of diabetes of the of perioperative care for patients with DM is a preoperative including the to and a for glucose A perioperative for people with diabetes has the to and for the for people with diabetes undergoing an of the the of with Diabetes Clin Scholar surgery, should on the assessment of the type of of glycaemic control and the of the diabetes-related complications such as cardiovascular and delayed glycaemic control and general of the increased risk of patients with have a higher prevalence of increasing their risk of and perioperative after surgery J. et on cardiovascular assessment and management of patients undergoing J. 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